Clinical briefing: Can pharmacists help diabetes remission?

A weight management programme has been shown to achieve remission in almost half of type 2 diabetes patients – and new data is suggesting the benefits persist for two years

Until recently, bariatric surgery was the only proven way to reverse the seemingly inexorable decline experienced by people with type 2 diabetes. The Counterpoint and DiRECT studies have changed this pessimistic view.1,2

DiRECT has shown that a weight management programme delivered by existing primary care staff achieved remission in almost half of type 2 diabetes patients.2 Now new data suggests that the benefits persist for two years.

After 24 months, 36 per cent of those who followed a weight loss programme remained in remission, down from 46 per cent after 12 months.3 “Community pharmacists could be proactive in making people with type 2 diabetes aware that remission is possible through weight loss,” Douglas Twenefour, deputy head of care at Diabetes UK told Pharmacy Magazine.

The Counterpoint study followed 11 type 2 diabetes patients (average body mass index [BMI] 33.6kg/m2) who consumed a 600kcal a day diet for eight weeks. Fasting plasma glucose normalised after one week of the low-calorie diet. Beta-cell function and hepatic insulin sensitivity also normalised, which was associated with decreased pancreatic and liver triacylglycerol stores.1

Promising results

DiRECT confirmed Counterpoint’s promising results. The intervention group replaced all their meals with soups and shakes providing 825-853kcal/day for three to five months. During the next two to eight weeks, they reintroduced ‘normal’ food following a structured programme.

Patients made monthly visits to maintain their weight loss and discontinued oral antidiabetic drugs and antihypertensives, which were reintroduced according to national guidelines.2

DiRECT enrolled 306 people with type 2 diabetes and BMIs of 27-45kg/m2 from 49 general practices. Of these, 21 per cent withdrew prematurely, usually for reasons unconnected with the study.

Body weight fell by means of 10.0kg in the intervention group and 1.0kg among controls. Mean HbA1c fell by 0.9 per cent and rose by 0.1 per cent respectively. After 12 months, 24 per cent of the intervention group lost at least 15kg compared with none of the controls.2

At 12 months, the intervention group was almost 20 times more likely to be in remission compared with controls (46 and 4 per cent respectively; odds ratio [OR] 19.7). Across both groups, no one who gained weight and 7 per cent of those who maintained a loss of 0-5kg entered remission. This proportion in remission rose to 34 per cent with 5-10kg loss, 57 per cent with 10-15kg loss and 86 per cent of people who lost at least 15kg. Quality of life improved significantly in the intervention group.2

Two-year benefit

In March, the researchers announced that the benefits persist for two years.3 At 24 months, the intervention group was more than seven times more likely to have lost at least 15kg (11 and 2 per cent respectively; OR 7.49). The intervention group was also almost 26 times more likely to be in remission (36 and 3 per cent respectively; OR 25.82). Again, quality of life improved more in the intervention group.3

However, between 12 and 24 months, mean bodyweight increased by 2.6kg in the intervention group and decreased by 1.3kg among controls. In the intervention group, those who remained in remission between 12 and 24 months regained a mean of 4.3kg. Those who relapsed after 12 months gained a mean of 7.1kg. HbA1c was 4.8mmol/mol lower in the intervention group compared with controls, despite 40 and 84 per cent taking antidiabetic drugs respectively. The authors concluded that the two-year results “show that continuing remission of type 2 diabetes is possible”.3

“For many people, especially those who are newly diagnosed, losing a significant amount of weight can help them achieve remission of type 2 diabetes – meaning maintaining a HbA1c below the threshold for diagnosing diabetes and coming off their glucose-lowering medications,” Twenefour says.

“Although people in remission should continue with regular diabetes monitoring, including retinal screening, achieving remission can have a huge impact on their quality of life.

“Even if remission is not achieved, losing weight can have other positive effects, such as reducing medications, feeling more energetic and potentially reducing the risk of diabetes-related complications.”

What are the costs per patient?

Delivering the DiRECT programme costs an estimated £1,223 a patient. The low-calorie soups and shakes account for most of this (£708). The costs of antidiabetic drugs and antihypertensives fell from means of £168 a patient in the first year among controls to £34 in the intervention group.

This and other savings meant the programme cost an estimated £1,067 a patient in the first year compared to controls. ‘Delivering’ a remission cost an estimated £2,564.4

The authors note, however, that the reduced healthcare demand might persist, so further follow-up of DiRECT will allow economists to model long-term health gains, the impact on resources and changes in quality of life.

The analysis also excludes the economic impact of other health gains associated with weight loss, which need further analysis. In the meantime, the authors say that “the case already seems strong for diabetes care budgets to offer the support for patients to attempt remission”.4

“It is important to re-emphasise that type 2 diabetes remains a serious condition, but it doesn’t have to be lifelong for everyone,” Douglas Twenefour concludes. “Community pharmacists could signpost people with type 2 diabetes to weight management services and encourage them to get the necessary support to lose weight as soon as possible.

“People with type 2 diabetes should also be encouraged to bring up the discussion about remission with their healthcare team at every opportunity.”

Poor adherence common in diabetes

Non-adherence is common among patients with diabetes in primary care, researchers from Leicester told the Diabetes UK Professional Conference recently.

Researchers used liquid chromatography-tandem mass spectrometry to detect antidiabetic and cardiovascular medications in urine collected from 256 patients. Of these, 5.5 per cent were totally non-adherent and 21.5 per cent were partially non-adherent to antidiabetic and cardiovascular medications.

Statins were associated with the highest non-adherence rates (21 per cent). After adjusting for confounders, the albumin-tocreatinine ratio, HbA1c and lipid profiles were significantly worse in non-adherent patients. (Diabetic Medicine 2019; 36 [Suppl 1]:9)

Read our interview with an Antrim pharmacist who has helped set up a successful diabetes management scheme in his local community.

References

1. Diabetologia 2011; 54:2506-2514
2. Lancet 2018; 391:541-551
3. The Lancet Diabetes & Endocrinology DOI: 10.1016/S2213-8587(19)30068-3
4. The Lancet Diabetes & Endocrinology 2019; 7:169-172

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